Saturday, October 8, 2016

Amongst the Native Americans of South Dakota, the infant mortality rate is one the highest in the nation at 11.47 deaths per 1000 live births. In Wisconsin, the infant mortality rate for black children is 14.00. Meanwhile, the infant mortality rate for white infants nationwide is 5.06 deaths for 1000 live births. (http://www.cdc.gov/nchs/data/nvsr/nvsr64/nvsr64_09.pdf)

In most of the world when it comes to childbirth midwives are the first to provide care. Here in the United States,
it’s a different story. Not only can it be difficult for an expectant
mother to find a midwife, but over the decades the male dominated
medical profession has done its best to demonize the women who practiced
midwifery.

For
centuries women handled society’s medical needs as both herbalists and
midwives. They brought us into the world, took care of us while we were
here and prepared the body for burial as we exited this life. Much of
that began to change with the rise of male-dominated, so-called scientific medicine.

In his book Of Foxes and Hen Houses; Licensing and the Health Professions author Stanley J. Gross notes

“[t]he
decline in the American midwife’s involvement in the birthing process
is not just attributable to enlightenment, new medical discoveries, or
to changing tastes, though all three are part of the story. More so, it
is the story of how a determined minority of medical men over several
hundred years was able to organize itself, inform the public of its
point of view, and use education, licensing, and monopolistic power to
impose their view on the public” (p. 59).

Midwives
naturally were present in the Native American tribes. Midwives came
from Europe with the colonists, were involved in establishing a European
presence in North America and most likely they were among the slaves
brought to the colonies. Midwives dominated the field of childbirth in
the early years in colonial America. As Paul Starr mentions in his book The Social Transformation of American Medicine; “(i)n colonial America… most medical care was routinely provided by women in the home” (p 49), but things began to change in the 1700’s.

Before the American Revolution women were involved in many aspects
of medical care, but in the period after the American Revolution, the
role of women was limited to the home. Now men dominated in politics,
business, education, science and medicine. Many doctors from the
colonies were trained in Europe and when medicine began to be taught in the United States women were barred from the medical schools.

Middle-class women began to look to men for medical care and assist in childbirth in the mid-1800s. Midwives were thought by some to be poorly educated, and they were reduced to caring for the immigrants in the urban
area. Some midwives who learned the trade as apprentices cared for the
poor in rural parts of the country, especially the south were the freed
blacks women known as grannies provided care for expectant mothers.

Unable to gain access to higher education women midwives were starting to take a backseat to male doctors (American Midwifery 1860 to Present p. 9). It wasn’t until the Boston Female Medical College opened in 1848 that midwives were able to receive formal training. (American Midwives, 1860 to Present, P 12)

The American Medical Association was founded in 1847 ( Amer. Mid. p58) and “the first modern medical practice act was passed in” 1873 by the State of Texas ( Gross p 57). In those early years,
the AMA was dominated by general practitioners. The rise of obstetrics
as a medical specialty had a profound impact on midwifery.

It has only been in the last few decades in the U.S. that doctors have assumed a major role in bringing children into the world.

The image of midwives was as much influenced by the social status of their clients as anything else. By the early 1900s midwives had been reduced to helping in the delivery of approximately 50% of infants in the U.S. According to Gross in Of Foxes and Hen Houses; Licensing and the Health Professions “The
next thirty years was a period during which midwifery would be outlawed
or ignored and turned into an officially despised and discredited
occupation…” (p.64)

It
was only about 1970 that midwifery began to make a comeback. Thanks in
many ways to the rise of feminism, the back to the earth movement and
the question authority attitude that was prevalent in those days.

One
of the more prominent voices in the movement to put women back in
charge of the birthing process was and continues to be Ina May Gaskin.
Ms.Gaskin might best be referred to as the Grand Dame of
the Farm, a commune in Tennessee that today has turned into a thriving
community of people who have developed a cooperative with a dozen or
more businesses.

Over the years Ms. Gaskin has written a number of articles on midwifery. Her first book SpiritualMidwifery
was published in 1977. The book, now in its fourth edition, has sold
worldwide, and has been a major influence on the birthing movement in
the U.S. No longer are so many women looking at birth as a medical
problem.

Depending
on whom you ask there are five to six different classifications of
midwives from Certified Nurse Midwives to Lay Midwife. All of this
depends on state laws and the organization certifying midwives. More
information can be found at American College of Nurse-Midwives and Midwives Alliance of North America.

“After
controlling for social and medical risk factors, the risk of
experiencing an infant death was 19% lower for certified nurse midwife
attended than for physician attended births, the risk of neonatal
mortality was 33% lower, and the risk of delivering a low birthweight
infant 31% lower. Mean birthweight was 37 grams heavier for the
certified nurse midwife attended than for physician attended births”.

Studies from Europe where midwives deliver most infants support this conclusion and in fact a study that compared 529,688 low-risk births from The Netherlands that took place at home and in hospitals showed no significant differences.

In Texas,
we see a significant difference in the quality between CPMs and other
groups. “Birth and death information from the Texas Department of Health
for 1990 -2000 indicate that birth with midwives in Texas has always
been a statistically safer option than birth with either a medical
doctor or doctor of osteopathy. State maternal mortality rates for all
kinds of birth attendants has been under 0.2/1000 since 1977. With
midwifery assisted births, infant death rates for 1990-2000 have never
exceeded 3/1,000. Births performed by either an MD or a DO have always
been at least twice as high as the published rate for midwives.” http://www.texasmidwives.com/PDFfiles/ATMsafty_study.PDF

Just over forty percent of all births nationwide are paid for by Medicaid, and in many states,
the number is significantly higher. Births by MDs costs two to three
times what midwives charge and deliveries by MDs are more likely to
result in questionable interventions, such as cesarean sections than
with midwives.

Medicaid paid for sixty-three percent of all birth in Louisiana in 2004 (http://www.kff.org/womenshealth/upload/8014.pdf).
Obviously where we find poverty we are likely to see more Medicaid
payments for childbirth and with the recent recession those numbers
have probably increased. So at a time when incomes are dropping for
expectant mothers and state revenues are declining, state costs for
Medicaid are increasing.

According to The National Hospital Bill published for 2006 (http://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.jsp) which does “not include outpatient care, emergency care for the patient
not admitted…or physicians fees” two of the “most expensive conditions
treated in U.S. hospitals” for 2006 where “Mother’s pregnancy and
delivery” number two at $47,800 million and “Newborn infants” at number
three and $38,184 million. http://www.hcup-us.ahrq.gov/reports/statbriefs/sb59.jsp In most areas where midwives practice today their costs are a third to a half of that of MDs.

In her book American Midwives, 1860 to Present, Historian Judy Barrett Litoff, notes, “…a frequent complaint expressed by physicians was that they were poorly reimbursed for their obstetric services. Many doctors feared that this trend would continue as long as midwives persisted in attending 50 percent of all the births for less than one-half the fee charged by medical practitioners”. [p 73]

Can we do something to lower these costs? Yes, we can and for the health of the mother and child we should. Most agree that the rates of c-section in the U.S. are two to three times higher than they should be. Every surgery carries risk,
and unnecessary surgery just leads to possible future problems.
Midwives might be a source in helping to lower the caesarean rate and
the reduction of other risks as well as helping to decrease the rate of
maternal mortality that has been increasing recently.

How
infant mortality is defined varies in some degree from one country to
the next, but for the most part, there are similarities. However, to
avoid problems, I suggest never compare infant mortality rates in the
U.S. with any other nation.

So do midwives benefit both mothers and children? Promoting Midwifery as a childbirth alternative for mothers may prove to be a benefit in a number of ways.

•Mothers
should be free to choose a doctor, a Certified Nurse Midwife, a
Certified Professional Midwife, a Licensed Direct Entry Midwife or
someone else if they wish.

•Midwives
may save tax dollars. The costs of births in New Mexico are some of the
lowest in the nation and midwives may help reduce those costs
significantly. When Medicaid pays for the birth, as it does in New
Mexico, and many other states, the costs drop, and the taxpayers
benefit.

•The
infant mortality rate in New Mexico was below the national average from
1994 until a jump in 2012 to just above the average that year. Today
the rate is close to the national average. This is much lower than other
low-income states and is an indication that health care providers in
New Mexico are among the best when it comes to birth.

END

This contribution is from Michael Wilson, Activist in the Libertarian Party of Washington.